Trauma: Abdominal Injury

Remember: Trauma Bundle

Opening Statement:

This is a critically unwell patient following a major trauma and I would ensure he is managed in the A&E resuscitation bay and that a trauma call has been put out with all members of the trauma team in attendance.

I would commence the primary survey following the principles of Advanced Trauma Life Support (ATLS) with simultaneous assessment and resuscitation of the patient in an A to E manner.

Airway and C-Spine Immobilisation:

• Assess airway patency using appropriate adjuncts if required
• Triple immobilisation of the cervical spine.
• Initiate 15L oxygen via a non-rebreather mask

Breathing:

Vitals:

• Oxygen saturations, respiratory rate

Assess:

• Palpate trachea
• Inspect chest during respiration for symmetry and bruising
• Palpate for chest expansion, flail segments and crepitus
• Auscultate and percuss chest for evidence of haemo/pneumothorax

Test:

• Venous/Arterial blood gas

Intervene:

• Nil in this scenario

Circulation:

Main concern:

• This patient is hypotensive and tachycardic and in the trauma setting I am concerned he is in hypovolaemic shock. I suspect an abdominal source of haemorrhage due to the severe abdominal pain, but I would also fully assess him for other sources.
• I would escalate to my seniors for early support. In the mean time I would begin my assessment.

Vitals:

• Heart rate, blood pressure, continuous cardiac monitor as in resus

Assess:

• Peripheral and central capillary refill times
• Peripheral pulse rate and character and JVP
• Auscultate heart sounds for haemopericardium
• Assess for source of haemorrhage (blood on the floor + 4 more - chest, abdomen, pelvis and long bones).
• Assess abdomen for bruising / guarding / peritonism suggestive of an abdominal bleed.

Test:

• Bilateral, large bore, IV access
• Trauma bloods: Full blood count, Urea & electrolytes, Liver function tests, clotting screen, lactate, group and screen or cross match if active haemorrhage
• Consider FAST scan locate any source of haemorrhage - focus on abdomen in this case
• 12-lead ECG

Intervene:

• Fluid resuscitation with 1000mls of a warmed crystalloid such as Hartmann's. Repeated as necessary.
• Consider transfusion of O negative or type specific blood in major haemorrhage.
• IV Tranexamic Acid 1g
• Consider activation major haemorrhage pathway.
• Re-assess following interventions and consider escalating patient at this stage.

Disability:

Vitals:

• Temperature

Assess:

• Major trauma with a significant risk of intracranial haemorrhage
• AVPU or calculate full GCS
• Pupil reactivity

Test:

• Blood sugar

Intervene:

• Patient warming to prevent hypothermia.

Exposure:

• Full top-to-toe examination for missed injuries whilst maintaining dignity and preventing hypothermia
• Secondary and tertiary surveys
• AMPLE history

Escalate:

• Early escalation to the senior members of your team for review
• Critically unwell patient requiring multidisciplinary management.
• Going to theatre bundle

Reassess:

• Continuous re-assessment in an A to E manner to monitor response to interventions or detect any deterioration in clinical condition.

The patient is critically unwell with evidence of shock. I am most concerned about an intra-abdominal haemorrhage, sources of which may include:

• Splenic rupture
• Liver laceration
• Genitourinary injury
• Retroperitoneal haemorrhage
• Vascular injury 

I would also exclude other sources of haemorrhagic shock

• Haemothorax
• Pelvic fracture
• Long bone fracture
• External injury

Although less likely in this scenario I would consider other sources of shock:

• Obstructive: Tension pneumothorax, cardiac tamponade
• Neurogenic/spinal

You have probably mentioned some of these already, but don’t be afraid to repeat yourself if the question is specifically asked.

• Bloods: Full blood count, Urea and electrolytes, Liver function tests, coagulation screen, lactate, cross match 4 units
• Arterial or venous blood gas
• FAST scan - can identify free fluid in abdomen
• CT Abdominal with contrast / CT Angiogram (this may be part of the trauma series) if the patient is stable enough for transfer

This is a haemodynamically unstable patient with a proven splenic laceration. He is likely to have a high grade splenic injury which may necessitate surgical or interventional radiological management.

• Escalate promptly to senior
• Reassess patient in A to E manner with appropriate resuscitation and consider blood products
• Multi-disciplinary management: Senior Trauma/General surgeon, radiologist, anaesthetist, critical care outreach, senior A&E clinician,
• Going to theatre bundle

Splenic injuries are graded following the American Association for the Surgery of Trauma (AAST) Organ injury scale.

1. Subcapsular haematoma <10% OR laceration through capsule <1cm in depth
2. Subcapsular haematoma 10 - 50% OR Intraparenchymal haematoma <5cm OR laceration through capsule 1 - 3 cm in depth
3. Subcapsular haematoma >50% OR Intraparenchymal haematoma >5cm OR ruptured subcapsular/intraparenchymal haematoma OR Laceration >3cm in depth
4. Laceration through segmental or hilar vessels causing devascularisation of >25% of the organ
5. Shattered spleen OR laceration through hilum which devascularises the spleen

Whilst you don’t need to memorise the entire system it is worth being aware of the criteria for higher grade injuries. Management of injury depends on the grade of injury and the haemodynamic status of the patient.

The management can be split into conservative, medical, interventional and surgical.

Conservative: The majority (60-90%) of splenic injuries are managed conservatively to preserve splenic function. This depends on the patient being haemodynamically stable with no evidence of ongoing haemorrhage. Therefore, conservative management is not an option here.

Medical: Fluid resuscitation to ensure the patient is not hypoperfusing their major organs. Blood transfusions with assistance from the haematology team to ensure platelets and coagulative function are maintained. Tranexamic acid 1g intravenously. Analgesia as needed.

Interventional Radiology: Embolisation of large or small vessels may be employed to stem haemorrhage. This is more likely to be utilised in stable patients with ongoing haemorrhage or those who fail conservative management.

Surgery: Patients with ongoing haemodynamic instability or proven high grade splenic injury may require laparotomy. Surgery may be able to repair parenchymal or vascular injuries, but if this is not possible splenectomy may be necessary. Following splenectomy patient require vaccination against encapsulated bacteria (Strep pneumoniae, haemophilus influenza, Neisseria meningitides) and consideration of prophylactic antibiotics.

Shock is life threatening circulatory failure resulting in inadequate tissue perfusion.

Shock can broadly be classified into four groups:

• Hypovolaemic: Haemorrhagic, GI losses, third space losses
• Distributive: Septic, anaphylactic, neurogenic, endocrine (Addisonian)
• Obstructive: Extra-cardiac disease suppressing LV output
• Cardiogenic: Arrhythmias, cardiomyopathy

See shock page.